Impacting Nurses’ Attitudes and Designing an IV Drip Reorder Form as Initial Steps of Pharmacy Decentralization at Loy

1. Discussion Introduction • The pilot project demonstrates the effectiveness of pharmacist-nurse interaction as shown in the literature reviewed. • Improvement in results of nurse communication level satisfaction suggests a starting point to develop successful interpersonal relationships between both parties. • Nurses verbalized appreciation for the form that will be utilized for the decentralized system • Implication of the form (Figure 1) is believed to: • Decrease in nurse waiting time • Decrease in order duplications • Increase nurse involvement with patient care • Improving IV drip delivery time is important because it improves patient health outcomes and nurse-patient contact time • Improving communication between nurses and pharmacists is vital for • Increased satisfaction between health care professionals • IV drip delivery turnaround time to be improved Pilot Units of Loyola University Medical Center: Coronary Care Unit (CCU) Medical Intensive Care Unit (MICU) Heart Transplant Unit (HTU) 2nd floor Intensive Care Unit (ICU) 4th floor Surgical ICU “A new decentralized system will provide better and more efficient delivery of medications.” • 10 nurses/nurse managers surveyed • Each student shadowed one or more nurses in the individually assigned unit over five weeks • REGARDING NURSE ATTITUDES • Communicated with nurses and administered survey (09/29/04) to assess their attitudes about the current system • Sample size = 10 nurses/nurse managers • Shared new information with the nurses about the outcomes of this pilot project, including the new IV reorder form and the future of the decentralization system • Administered post-survey to assess any difference(s) in nurse attitudes (10/20/04) “How would you rate the IV delivery system right now?” • 10 nurses/nurse managers surveyed • 1-3: needs improvement • 4-6: average • 7-10: satisfied with the IV delivery system • Sources:www.pamf.org/images Study Limitations • The decentralized system has not been fully implemented and presents certain limitations: • Lack of data on system effectiveness • Lack of data on technical support for the new system • Surveys utilized in this pilot project presented some limitations, in that there was: • Lack of quantitative data • Small sample size • Time restraints: five weeks for pilot project • External validity questionable due to limited pilot units utilized in the study REGARDING IV DRIP DELIVERY TIME • Tracked reorder and delivery time of IV drips Initial IV Drip Reorder and Delivery Time • CCU: 30-35 minutes • MICU: 30 minutes • HTU: 30 minutes • 2nd floor ICU: 25 minutes • 4th floor ICU: 30-40 minutes • IV drip medications were patient-specific and individually titrated according to appropriate lab parameters • Reviewed patient charts for IV drip titration rates • Created an IV drip reorder form that pharmacists will use upon implementation of the decentralized system IV Drip Reorder Form Literature Review #1: Nurse Impact of Decentralization “I have to reorder IV drips often over 2-3 hours before the scheduled time.” • 10 nurses/nurse managers surveyed “What is the longest you have waited for an IV drip?” • 10 nurses/nurse managers surveyed • A nurse survey prior to and after decentralization was administered in a three-year study at both University of Michigan hospital and Mott Children’s Hospital. • Study outcomes reported by authors: • Satisfaction levels of nurses • Units BEFORE AFTER • 6th & 7th floors (decentralized) 47.4% 66.1% • 8th floor 67.7% 64.6% • 9th floor (decentralized) 45.9% 78.2% • Psychiatric wards (clinical RPh) 40.0% 79.3% • Mott’s 80.6% 76.4% • Through Chi-square analysis (p<0.05), the authors detected a SIGNIFICANT differences in all DECENTRALIZED floors • Authors’ Conclusions • Overall, the change in nurse attitude was not significantly influenced by medication delivery time but rather, pharmacist-nurse interaction • (Ross MB, Ryan ML. Nurses’ attitudes toward pharmaceutical services before and after decentralization. Amer Journ Hosp Pharm 1988 Feb;45:351-6.) Results From Six Survey Questions Literature Review #2: Installation of Satellite Pharmacies Attitudinal surveys of nurses and pharmacists before and after installation of satellite pharmacies were conducted, 9 months apart, at a 600-bed University of Illinois hospital. Survey categories: role conflict, ambiguities, communication obstacles and asymmetries Study outcomes reported by authors: Only 5 out of 13 pharmacists’ satisfaction scores improved significantly. In contrast, 10 out of 15 nurses’ satisfaction scores improved significantly. Authors’ Conclusions Both parties agreed on decreased phone communications and increased understanding of drug distribution process. (Thompson DF, Kaczmarek ER, Hutchinson RA. Attitudes of pharmacists and nurses toward interprofessional relations and decentralized pharmaceutical services. Amer Journ Hosp Pharm 1988 Feb;45:345-51.) Source: www.uihealthcare.com Results Projected Outcomes Methods • Pilot project conducted is the primary step in the decentralization process • More efficient IV drip delivery time should: • Improve patient outcomes • Decrease medication errors • Be cost-effective Global Goal • A decentralized pharmacy will improve patient outcomes Specific Study Objectives • Creation of an IV drip form will improve medication delivery time • Improving nurse attitudes towards pharmacists will lead to successful interprofessional relationships • IV drip delivery system • In the current IV delivery system, there was a decrease (50% to 20%) in rating 1-3 and an increase (20% to 50%) in rating 7-10 • Timely delivery of medications: • 20% agreed in post-survey about timely delivery of medications • 20% strongly disagreed and 50% disagreed in pre-survey while 10% strongly disagreed and 40% disagreed in timely delivery of medications • For IV medication delivery wait time, there was a 20% increase in 16-30 minutes, 30% increase in 46 minutes – 1 hour, and a 50% decrease for > 1 hour. • Communication level between nurses and pharmacists • 40% increase in nurse rating of communication level = 4. • No nurses rated the current communication level as 5 (no changes needed) • Decentralized system implementation • In pre-survey, 10% stated “MAYBE” but in post-survey, 100% agreed on benefits of implementing the decentralized system Impacting Nurses’ Attitudes and Designing an IV Drip Reorder Form as Initial Steps of Pharmacy Decentralization at Loyola University Medical Center “Most of my IVs come to the unit on time.” • 10 nurses/nurse managers surveyed Background Information Denisa Olarescu, Suman R Saini, Sandy Tiao, Charlene Yang, Maria Yu Preceptors: Richard Ricker, RPh, MBA and Cheryl Gallagher, PharmD, MJ, CGP Sources: http://root.main.uab.edu “How is the communication level between yourselves (nurses) and pharmacists?” • 10 nurses/nurse managers surveyed • 1: needs improvement • 5: no changes needed Sources: www.bnn-online.co.uk • Literature Review #3: Comparison of Medication Distribution Systems • In Sophia Children’s Hospital in the Netherlands, a three • month study was conducted comparing the efficiency of • drug distribution between a ward stock system and a • decentralized pharmacy. • The average time was measured for the distribution • process such as preparing IVs and administering the • medications. • Study outcomes reported by authors: • Nurses spend more time (average 4 minutes) than • pharmacy technicians (average 2.42 minutes) preparing • medications. • Authors’ Conclusions: • With the satellite pharmacy, pharmacists spend more time • as ‘therapeutic consultants.’ Therefore more attention is • given to patient care. (Poley MJ, Bouwmans CA, Hanff LM, Roos PJ, van Ineveld BM. Efficiency of different systems for medication distribution in an academic children’s hospital in The Netherlands. Pharm World Sci. 2004 Apr;26(2):83-9.) Study Implications Future Research Avenues • After reviewing the existing literature available and conducting the pilot project, a decentralized system should in long-term: • Benefit patients • Benefit health care providers (HCPs) • Improve working relationships between HCPs • Provide higher quality patient care • Follow-up on the: • Nurses’ attitudes toward the pharmacists • Interpersonal relationships between nurses and pharmacists • Effectiveness of the IV drip order form (Figure 1) in terms of medication delivery created in this project • Process of decentralization • Future challenges with the new decentralized system once implemented Figure 1